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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ----------I-------4,11-1------- ------------- _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued .—.a _ � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ __. _ _-----------------_------------CENSUS TRACT -------------- ........... Owner's Name _170/7; e-&-s---------------------------------------------------------------- -------Phone Address ------%57""a-ll-,;,7-e/___ ------------------------------------------•---_-. City _ /- 1a/ r/ --------------------------------------- Contractor's Name ______._._- ------------------------License # v Phone s' _'%1��. Installation will serve: Residence ❑Apartment House,❑ Commercial [-]Trailer Geust Motel ❑Other ------------------------------------------- Number of living units:--- ----- Number of bedrooms ---�.�__-___-_Garbage Grinder/ °__ Lot Size a_,C_4e-e,_f------------------------- Water Supply: Public System and name ---------------------- ----------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If yes,type -------------_..__-_____._ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) / S ' PACKAGE TREATMENT ( ] SEPTIC TANKSize-_1, _j__. .. .,if_ __--_-__._______ Liquid Depth _ .y_________________An Capacity/;W- - _____-_. Type�j_"6 OV"Material No. Compartments _Z-.............w Distance to nearest: Well __ ,�,�_____________________Foundation _,lA41,------------ Prop. Line .4�...._.___...� LEACHING LINE No. of Lines -------/______________ Length ofeachline_`��_--------------- Total Length _/_P ------------------ - _ 'D' Box �e-_ Type Filter Material - A ----Depth Filter Material `�'� ............... ` ` s Distance to nearest: Well -A?- ___-__-``-__ Foundation Ae---__---_.__ Property Line r>fP............... SEEPAGE PIT Jf(J Depth ._��______ Diameter ��------- Number _ _/-----------------___ Rock Filled Yesf. No 0 Water Table Depth --- --------------------------------Rock Size ------------ /A0_1 i f � r Distance to nearest: Well ___ _________________________Foundation ,1� =/--- Prop. Line A-P..--.......--... REPAIR/ADDITION(Prey. Sanitation Permit C# ________________________________ _ Date -----------------------------------) Septic Tank (Specify Requirements) -------------------------------------------------------------------------------- ------ ----------------------------- Disposal Field (Specify Requirements) .____.______ ------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------- ----- -----------4oer) ----- - --- Owner BY - - Title ----- ---------- ------------------------- ----------------------------- -------- ---------- ------------------------ - o her than FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ _ _ DATE -------- BUILDING PERMIT ISSUED ------------------- ------------------------------------------------- ----------------------------------DATE ---------------------------------------- ADDITIONALCOMMENTS --------------------------------------------------- ------------------------------------------------------------------------------=---------------- --------- ------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - -- ' -- -------------------------------- ------ ------------------------------------------------_-- --------�---'--_-/----.---_-_ ----------- Final Inspection b Z ______________Date ------ SAN JOAOCAL HEALTH DISTRICT h E. H. 9 1-'68 Rev. 5M